Release Notes:
Data Element
Version 2010B
| Data Element Name: | Contraindication to VTE Prophylaxis |
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| Collected For: | , , |
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| Definition: | Contraindications to pharmacological and/or mechanical venous thromboembolism (VTE) prophylaxis. |
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| Suggested Data Collection Question: | Is there documentation by a physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist in the medical record of contraindications to pharmacological and/or mechanical VTE prophylaxis? |
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| Format: | | Length: | 1 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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| Allowable Values: |
1 There is physician/APN/PA or pharmacist documentation of contraindications to mechanical VTE prophylaxis
2 There is physician/APN/PA or pharmacist documentation of contraindications to pharmacological VTE prophylaxis
3 There is physician/APN/PA or pharmacist documentation of contraindications to both mechanical and pharmacological VTE prophylaxis
4 There is no physician/APN/PA or pharmacist documentation of contraindications to either mechanical or pharmacological VTE prophylaxis or unable to determine from medical record documentation.
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| Notes for Abstraction: |
- Documentation for allowable values 1-3 must be found within the timeframe of arrival to 24 hours after Surgery End Time. It is not necessary to review documentation outside of this timeframe to answer this data element.
- See the inclusion list for acceptable contraindications to prophylaxis. The list is not all-inclusive.
- An allergy or adverse reaction to one type of pharmacological prophylaxis would NOT be a contraindication to all pharmacological prophylaxis. Another medication can be ordered.
- A physician-documented contraindication to one type of prophylaxis does not mean the patient has a contraindication to all prophylaxis.
Example:
The physician documents “Patient is at risk for bleeding, no anticoagulants.” Select “2.”
- The physician documents “Patient is allergic to coumadin.” Do NOT select that the patient has a contraindication to all pharmacological prophylaxis because that is not documented. Select “4.”
- If the physician orders a transfusion and the blood products are administered in the timeframe of arrival to 24 hours after Surgery End Time, select “2.”
- To select value “3,” there must be documentation of contraindication to BOTH mechanical and pharmacological prophylaxis.
Example:
There is physician documentation that a trauma patient has active bleeding and fractured femurs bilaterally. Select “3.”
- Patient refusal does not have to be documented by a physician/APN/PA, but it must be documented in the timeframe of 24 hours prior to surgery to 24 hours after Surgery End Time
- If there is physician documentation of bleeding risk associated with surgery, do not consider this a contraindication to pharmacological VTE prophylaxis
Example:
The physician documents, “Discussion of risks and benefits included risk of infection and bleeding.”
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| Suggested Data Sources: |
ONLY PHYSICIAN/APN/PA OR PHARMACIST DOCUMENTATION OF CONTRAINDICATIONS:
- Anesthesia record
- Consultation notes
- Discharge summary
- History and physical
- Physician orders
- Physician progress notes
SUGGESTED DATA SOURCES FOR PATIENT REFUSAL (other than physician/APN/PA documentation of contraindications as above):
- Medication Administration Record
- Nurses notes
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion |
Contraindications to mechanical prophylaxis:
- Bilateral amputee
- Patient refusal
- Bilateral lower extremity trauma
Contraindications to pharmacological prophylaxis:
- Active bleeding (gastrointestinal bleeding, cerebral hemorrhage, retroperitoneal bleeding)
- Bleeding risk
- GI bleed
- Hemorrhage
- Patient refusal
- Risk of bleeding
- Thrombocytopenia
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Orders to hold prophylaxis without a documented reason or contraindication
Contraindications to pharmacological prophylaxis:
- History (Hx) of bleeding
- Bleeding risk described in the informed consent process
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Contraindication to VTE Prophylaxis
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)
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